~ : Case Study 4 : ~

~ : Diagnosis and Treatment Planning Group Presentations : ~

Eliza is a new arrival from England. She doesn’t like the appearance of her upper left central incisor.

Criteria:
Prepare a 10-15 PowerPoint presentation on the case study which covers the following points:

• Description of patient and clinical presentation
• Etiology of the clinical problem
• Factors which may have contributed to the situation
• Treatment plan which reflects a holistic approach to the care of the patient.
• Provides an evidence base for their diagnosis and treatment planning

Date for presentation: Tuesday 15 September at Somerton Pk at 10.30am

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Sequelae: a condition following as a consequence of a disease.

Things to think about:

• Aesthetics
• Occlusion
  • crowding potentially on currently errupting teeth
  • orthodontic work possibly needed.
  • teeth chipping?
• gingivaitis -localized
  • caries potential due to plaque build up - fluoride and good OHI
  • calculus build up
• chronic Inflammation and aggitation due to composite resin materials.
• Sensitivity issues
• Hypermineralisation (Hyperplasia)
  • 11 - fluorosis
• trauma
  • tooth chipping (11)
  • to the gingiva - oral pathology?
  • Upper central incisors are the teeth which are most commonly affected by traumatic injury.
  • Majority of traumatic injuries occur between 1 and 4 years old which is during the developmental stage of the permanent crown.
• Localised hypoplastic defect –
  • trauma in the primary dentition may cause developmental disturbances in the unerupted permanent teeth.
  • This disturbance can occur as the distance between the primary tooth and its successor is relatively close.
• Patient age at which the trauma occurs
  • as this dictates the impact it will have on the permanent tooth in relation to the type and degree of damage.
  • At a younger age the crown of the permanent tooth is likely to be affected, however if the trauma occurs at a older age the root can also be damaged.
  • Hence, it is important to assess if the permanent root of the central incisor has been affected/damaged in a particular way.
• Role as a therapist (scope of practice) - refer to dentist or pedodontist.

• Dilaceration

Definition - deviation or bend in the linear relationship of a crown of a tooth to its root

Dilacerated teeth generate diagnostic, management and prognostic challenges; they effect restorations, endodontic therapy, extraction and orthodontics. Consequently it is important to recognize dilacerated teeth before treatment begins.

Cause
Mechanical trauma to the primary predecessor tooth resulting in dilacerations of the permanent successor. Damage frequently occurs after avulsion or intrusion of the primary tooth.
The developing permanent tooth germ is displaced and develops at an angle to the part of the tooth germ which has calcified.
Idiopathic developmental disturbance – if no clear evidence of a traumatic injury
Additional contribution factors may include:

• Scar formation
• Developmental anomaly of the primary tooth germ
• Facial clefting
• Advanced root canal infections
• Ecotpic development of the tooth germ
• Lack of space
• Effect pf amatp,oc structure – cortical bone of the maxillary sinus, mandibular canal, nasal fossa
• Presence od – adjacent cyst, tumor or odontogenic hamartoma e.g. supernumerary tooth
• Orotacheal intubation?
• Laryngoscopy?
• Mechanical interference with eruption e.g. ankylosed primary tooth that does not resorb
• Tooth transplantation
• Extraction of primary teeth
• Hereditary factors

Location
Depend at the stage of development of permanent successor
Can be:

• Within the corwn
• Cemento-enamel junction
• Any where along the length of the root
• Root apex

Crown dilacerations
Less common
Usually occure in maxillary permanent incisors due to the close proximity to the primary incisor
Upper incisors – commonly crown dilacerations are angled palatally
Lower incisors – commonly crown dilacerations are angled labially

Root dilacerations
More common

Radiographs
Assist with detection of dilacerations, however when dilacerations are labial/buccal or palatal/lingual diagnosis is problematic. Radiographs would need to be taken from different angles to assist with diagnosis.

Endodontic procedures
Effectiveness relies on:

• The severity of the dilacerations
• practitioner skills
• Why the endodontic procedure was required
• How much tooth structure remains

Patient Description (#2494d6 - colour)

Age:

• Approximately 9-10yrs
• Female

Clinical Presentation

Teeth Present:

• 41
• 31
• 32
• 22
• 21
• 11

Soft Tissues:

• Stippling
• coral pink in most areas
• red laceration to gingival margin of the 21
• both interdental papillae of the 22 are red/inflamed
• mucogingival junction of the 22 is more inflamed more than the remainder
• Moist and shiny - good saliva
• Bulbous, protruding gingival margins of max. incisors.
• potential lip bite lesion on inner labial adjacent to the 31.
• diastema approx. 2mm.
• localised gingivitis, deep red oedma soft tissue appear very irritated

Hard Tissues:

• mamelons present on lower incisors
• 21
  • cervical third discoloured
  • 21 incisal chip - middle - dentine exposure - potentially hypoplasia?
  • potential dilaceration - Sequelae of trauma
  • has been restored - material CR or GIC?
    • While the perm. tooth and surrounding tissues are developing - the tooth may have been restored for aesthetic purposes.
    • Once perm. tooth is completely developed perm. treatment options can be considered - endo/crown, implant
  • gingival margin has irritation - red and inflamed.
    • potentially plaque is getting stuck on the restoration's margins - causing inflamation.
    • material irritating gingiva (only if a CR)

Possible Contributing Factors

• sequelae of luxates or avulsed primary incisors - develppmental disturbances of the permanent tooth
• damage to permanent dentition occurs more often with intrusive luxation and avultion
  • depend on:
    • direction and displacement of the primary root apex
      • potentially in this case the child fell with something in their mouth causing the crown to move labially and the roots to move palatally - therefore disrupting the development of the permanent tooth. (fig.2)
    • degree of alveolar damage
    • stage of formation of the permanent tooth

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Treatment Plan (holistic and evidence-based)

Further info needed:

1. Try to get case notes from Eliza’s previous dental practitioner to obtain previous treatment, or if trauma has been documented to assist with diagnosis, prognosis and appropriate treatment plan.
2. Thorough dental, medical and social history - to assist with accurate diagnosis
3. need radiographs - set of bitewings + PA of the 21

· If abscess present-pulpectomy or extraction possibly needed
4. Clinical exam – determine whether this occurred recently or previously:
· Soft tissues – foreign bodies?
· Hard tissues – infractions and fractures
· Pulp exposures?
· Mobility?
· Percussion testing – damage to PDL
· Cold and electric pulp test.

Diagnosis:

• hypoplasia - masked with composite resin?
• dilacerted tooth -Attempted to be restored?
  • Extremely difficult when defect at gingival margin.
  • Questions need to ask – how it occurred?
    • Has there been previous injury to the teeth?
    • How did the injury occur (indicates extent of injury)?
    • Where the injury occur (contamination etc)?
    • Is there a disturbance in the bite? – (difficulty to chew/talk etc)

Patient and parent options:

1. If dilacerated tooth
   1. Explain to parent extent of damage:
      1. that possible previous trauma to primary tooth may have caused permanent successor to be dilacerated (bent)
      2. 25% of children do have developmental disturbances of permanent tooth.
      3. damage to permanent tooth occurs more often with intrusive luxation & avulsion in very young children
   2. Inform that not much can do in terms of treatment - may have to wait until Eliza is older
   3. Steps of treatment
      1. If tooth discoloured and asymptomatic
         1. No treatment
         2. Mask with composite resin (appears this is what they have attempted to do)

3. Surgical exposure and bonding of chains or brackets for orthodontic extrusion
4. Severe cases may be untreatable and may need to be removed
5. Refer to pedodontist/dentist
1. Once permanent tooth and alveolar bone is completely developed - endo/crown, or implant can be considered.


Lastly:

1. Recall, monitor, review

References:

• Bath-Balogh, M & Fehrenback, MJ 2006, 'Dental Embryology, Histology, and Anatomy', 2nd edn, Elsevier Saunders, St. Louis, Missouri.
• Cameron, AC & Widmer, RP 2008, 'Handbook of Pediatric Dentistry', 3rd edn, Mosby Elsevier, China.
• Jafarzadeh H and Abbott PV, 2007, ‘Dilaceration: Review of an Endodontic Challenge’, The American Association of Endodontics, No: 9, Vol: 33, pp 1025 - 1030
• Lippincott Williams & Wilkins 2007, 'Stedman'd medical Dictionary for the Dental Professions', Wolters Kluwer Health, RR Donnelley, USA.
• Pinkham, JR, Casamassimo, PS, Fields, HW, McTigue, DJ & Nowak, AJ 2005, 'Pediatric Dentistry - Infancy Through Adolescence', 4th edn, Elsevier Saunders, St. Louis, Missouri.